Patient- and Family-Centered Care: Approaches for Children and Seniors

Web EventJuly 22, 2014

Follow this event on TwitterHashtag: #AHRQIX

1

Using the Webcast Console and Submitting Questions

Click the Q&A widget to get the Q&A box to appear

To submit a question, type question here and hit submit.

2

Accessing Presentations

• Closed Caption

► Click on the “Closed Caption” widget

• Download slides from console

► Click on the “Download Slides” widget for a PDF version

3

What is the Health CareInnovations Exchange?

• Publicly accessible, searchable and downloadable database of health policy and service delivery innovations

• Searchable QualityTools

• Successes and attempts

• Innovators’ stories and lessons learned

• Expert commentaries

• Learning and networking opportunities

• New content posted to the Web site every two weeks

Sign up at http://www.innovations.ahrq.gov under “Stay Connected”

4

Innovations Exchange Web Event Series

• Archived event materials are available from the Events & Podcasts tab at http://www.innovations.ahrq.gov. These include:

► The May 2014 Web event in this series, “Patient- and Family-Centered Care for Adults with Chronic Conditions”

► Today’s Web event will be available within two weeks

5

Patient- and Family-Centered Care: Approaches for Children and Seniors

Beverley H. JohnsonInstitute for Patient- and Family-Centered Care

6

Patient- and Family-Centered Core Concepts

• People are treated with respect and dignity

• Health care providers communicate and share complete and unbiased information with patients and families in ways that are affirming and useful

• Patients and families are encouraged and supported for participation in care and decision-making at the level they choose

• Collaboration among patients, families, and providers occurs in policy and program development and professional education, as well as in the delivery of care

7

Patient- and Family-Centered Core Concepts

Patient- and family-centered care is working with patients and families, rather than to or for them

8

Why Patient- AND Family- Centered Care?

• Individuals who are most dependent on health care are most dependent on families:► Those with chronic

conditions

► The very young

► The very old

• Families are allies for quality and safety by:► Providing constant support across settings and

assisting with transitions of care► Participating in developing care plans and supporting

patients in following plans9

Hasbro Children’s HospitalProvidence, Rhode Island

• Family Advisory Council

►Communicates needs of families

►Fosters partnerships among families and health care professionals

►Provides mechanism for families to provide input for policies, programs, and facilities

10

Hasbro’s Family Advisors

• Family advisors serve on the following:

► The Patient- and Family-Centered Care Steering Committee

► The Healthy Hospital Initiative

► The Zero Harm Committee

► The Safety and Quality Committee

► The Family Rooms Subcommittee

11

Hasbro’s Family Advisory Council

• Family Advisory Council Current Priorities:► Alternative Medicine Programming: working with

Palliative Care Service

► Safety and Security: working with Security Department to enhance building security

► Nutrition: working with Food and Nutrition Department to improve healthy options for children and families

► Physical Environment: re-sign outdoor play area

12

Hasbro’s PFCC Rounds

• Patient- and Family-Centered Care (PFCC) Rounds► Shadowed physicians and multidisciplinary team

members on daily PFCC rounds

► Created a video about rounds that will be used for teaching; also available on the GetWell Network for patient and family education

13

Family-Based, Integrated, Day Treatment for Children and Adolescents with Complex Pediatric Illness

Michelle Rickerby, MD

14

Hasbro’s Children’s HospitalDiane DerMarderosian, MDHasbro’s Children’s Hospital

Frontline Innovators on Providing Patient- and Family-Centered Care

15

Acknowledgements

• Patients and families with whom we partner

• Program’s entire multidisciplinary team

• Program Founders

► Tom Roesler, MD

► Pamela High, MD

• Patient and Family Centered Care Manager

► Fran Pingitore, MSN, RN, PCNS-BC

16

Hasbro Children’s Partial Hospital Program

A joint program of the Department of Pediatrics and Division of

Child Psychiatry that treats children with both medical and emotional illness

17

What We Hope to Accomplish

• The Hasbro Children’s Partial Hospital Program (HCPHP) treatment model

• We serve patients and families by:

► Joining with families “where they are”

► Recognizing parents as the experts on their children and patients as the experts on their own experiences

► Coordinating care and services from a multidisciplinary team that

includes parents

► Using day treatment to maximize sustainable home-based success

18

Parent Reflections

“The family needs to be part of the team that supports the patient’s recovery. This collaborative effort between staff and family is critical because the family knows the child best. The family is able to communicate their observations to the staff. This helps the staff and hopefully quickens the recovery process.”

- “EC,” parent

19

How We Do It

We partner with patients and families to build an better understanding of the illness and support family strengths and relationships to promote

health and well-being.

20

Structure of the Program

• Eight hours a day, 5 days a week

• Two age groups: 6 to12 years and 13 to18 years

• Median length of stay: 18 to 20 days

• Approximately 190 admissions per year

21

Admission Criteria

Either

• Presence of both a medical illness and a psychiatric condition affecting the medical problem

• Patient stable; does not require 24-hour hospitalization

• Inpatient discharges, if patient is high risk of re-hospitalization within days or weeks

• If patient was treated on outpatient basis, medical and psychiatric treatment failed and the patient has significant impairment of daily activities

Or

• Inpatient admission is anticipated within days or weeks because of deteriorating condition

22

Common Illnesses• Diabetes

• Eating disorders

• Inflammatory Bowel Disease

• Migraine headaches

• Encopresis

• Somatoform Disorders

Common Challenges• Disordered eating

• Medical non-adherence

• Functional syndromes

• School avoidance

• Coping with chronic illness

• Medical child abuse

23

Typical Patient Experiences

• Nutritionist

• Social workers

• Teachers

• Milieu therapists

• Collateral providers

• Patient and family

• Child and family psychiatrists

• Pediatricians

• Psychologists

• Nurses

Treatment Team

Program Model

25

26

Meeting Families Where They Are and Supporting Empowerment

• Understanding of the illness

• Impact of illness on family relationships

• Pre-existing challenges

• Identifying opportunity amidst crisis

“Family-Based” Decision Making

• Not simply “involving the family”

• Not just using family therapy as a modality

• Understanding that the family and patients are experts

• Making every decision from the perspective that the family’s understanding of the illness and family relationships constitute a powerful force in illness management/recovery

27

“Integrated”

• Not simply the concept of integrating physical and psychological issues

• The integration of modalities (pediatric care, psychotherapy, case management, psychopharmacology) through consistent provider communication and provision of coordinated messages to families and patients

28

Family Empowerment Experiences

• Daily nursing support and education

• Pediatric medical monitoring /treatment with integral involvement of patients and families

• Nutrition education meetings

• Family support groups

29

Family Empowerment Experiences

• Parent training within skill-building curriculum

• Family therapy

• Close collaboration with the family’s healthcare providers; both the patient’s and those treating parents/siblings

• Support family members in caring for themselves

30

The “Good News” of High Intensity Challenges

• A trusting partnership with patients and families is critical to improving patient outcomes

• If we “know where we are,” we know what to do

• Consistent messages matter and are powerful

• Excellent provider collaboration is a strong force in supporting patient/family success

• Any painful challenge/symptom/illness is improved with an empowered set of beliefs and empathic relationships

31

Patient Reflection

“The Partial Hospital Program was the best thing that ever happened to me. It changed my life.”

- “DD,” 12 years old

32

Questions?

Click me to get Q&A box to appear

33

Patient- and Family-Centered Care for Seniors and Their Families

Beverley H. Johnson

34

The Ambulatory Setting

35

Partnering with an Older Patient and his Family Caregiver

The Inpatient Setting

• AHRQ study of Geriatric Academic Rounds at the bedside with the patient and family at The Christ Hospital, Cincinnati, OH

• Patient and family advisors were a part of this research and the practice change

Health of Populations

Patient Experience

36

Hospital Care Unusually Stressful for Older Patients

•Social Isolation is a risk factor

•Research findings:

►Isolating patients at their most vulnerable times from the people who know them best, places patients at risk for harm and costly unnecessary care*

► For many older patients, hospitalization for acute/critical illness is associated with reduced cognitive function**

*Cacioppo &Hawkley, 2003; Clark, Drain, & Malone, 2003 **Ehlenbach, et al, 2010

37

Patient- and Family-Centered Approaches for Older People

Families and other care partners are more keenly aware of any change in cognitive function than hospital staff and, therefore, are a valuable resource during hospitalization.

38

• “The family is respected as part of the care team—never visitors—in every area of the hospital, including the emergency department and the intensive care unit”

Leape, L., Berwick, D., Clancy, C., & Conway, J., et al. (2009). Transforming healthcare: A safety imperative. BMJ’s Quality and Safety in Health Care. Available at: http://qshc.bmj.com/content/18/6/424.full.

• Campaign to eliminate restrictive visiting policies in 1,000 hospitals by 2017 — to access an array of resources to begin a process of change: www.ipfcc.org/bettertogether/

39

Atlanta’s Emory Healthcare’s Goal: Transform health and healing by developing and implementing innovative, patient- and family-centered care, research, and teaching models

Initiatives:

► Designed clinical space to facilitate interdisciplinary, patient- and family-centered approach to care delivery

► Created and implemented 2-3 specialty-based patient and family advisory councils in each facility; appointed advisors to at least 5 quality and facility committees/initiatives system-wide

Result:► Over 2-yr period, patient experience scores improved 40 percentage

points for overall nursing care and for how well pain was controlled

40

Leadership to Build A Patient- and Family-Centered System of Care

Further Evidence of the Value of Patient and Family Partnership

Patient and family advisors participated in facility design planning AND in the design of care processes for Emory’s new Orthopaedics & Spine Hospital at Emory. Results:

► Patient satisfaction has been at or above 96th percentile since the hospital opened in 2008

► Length of stay is one day shorter than benchmarked specialty hospitals across U.S.

► Patient and family advisors continue to participate in hospital councils and other change processes

41

Building Partnerships in Emergency Care

Contra Costa Regional Medical Center held “value stream mapping” event to improve behavioral health emergency care; involved patient and family advisors. Results:

► 50% reduction in average number of patients leaving the emergency department (ED) prior to receiving care

► Saved 255 staff hours/month spent obtaining patient medical clearances in ED

► Reduced assaults/aggressive acts in ED

► Percent of patients returning home with a full discharge plan grew from 50% to 90%

► Reduced % of patients discharged on multiple psychotropic drugs

42

Holy Cross Hospital Seniors Emergency Department

Judith Rogers, PhD, MSN, RNHoly Cross Hospital

43

Frontline Innovators on Providing Patient- and Family-Centered Care

44

Holy Cross Hospital Characteristics

• Full service acute care hospital founded in 1963 by the Sisters of the Holy Cross

• 1,366 member medical staff and 442 licensed beds, including 46 neonatal intensive care units; second largest hospital in region

• Only teaching hospital for medical education in County

• Revenue of $387 million

• Community benefit of $48 million, including $26 million of financial assistance

45

• Services

► 31,981 discharges and 182,593 outpatient registrations

► 90,232 emergency visits

• Workforce

► 3,393 employees; 68.3% minority

► Workplace Excellence award for 14 consecutive years

► Stable workforce; no layoffs

Note: All statistics are for fiscal year (FY) 2013

46

More Characteristics

Community Demographics

• Culturally and ethnically diverse; Of the 1.7 million residing in the overall service area:

► 37% Black, 31% White, 19% Hispanic, 10% Asian, 3% other

► 12% Seniors 65+ (210,813)

• Rapidly aging; seniors 65+ projected to grow 23% by 2018, compared to 2% for ages 0-64

► Note: all statistics are for FY13 unless otherwise identified

Primary Service Area Secondary Service Area

47

Purpose of Seniors Emergency Department (ED)

• Focus on improving:

► Patient care

► Patient experience

► Staff engagement and satisfaction

► Health care resource allocation

► Readmission rates

► Complication rates

► Length of stay

► Payment denials/reimbursement risks

48

Seniors ED Goals

• Optimize utilization of both in- and outpatient resources

• Establish effective and expedient outpatient resource access and care transitions

• Prepare for the fact that acute care episodes are often accompanied by:

► Functional decline

► Increased dependency

► Increased morbidity

49

Focus on Patient and Family

• Respect and dignity

• Information sharing

• Engagement

• Collaborative decision making

• Partnerships/allies

• Participation as part of the team

• Create constant support systems

50

The Value of Family Engagement

• We learn from the family

• Family helps steward the plan of care

• Better outcomes are supported by greater family engagement

51

Our Approach

• To care for Mary was to care for something larger

• Caring for Mary’s husband was part of that something larger

• When family is not present or involved, care is compromised:

► Difficulty in providing optimum acute care services

► Questionable follow-up

► Challenged transitions of care

52

Making the Connection

• Create a sustainable infrastructure

• Partner with loved ones in the care of seniors

• Create a “one person” interface

► Sincerity

► Authenticity

► Genuine

53

Staff Engagement

• Supports the mission of Holy Cross Health

► Be the most trusted provider in the community

• Organization-wide focus on seniors

► Partner with Erickson School for all-leader engagement

► Acute Care of Elders: includes multidisciplinary rounds three times per week for all patients included in program

► Seniors Emergency Department

► Seniors Ambulatory Surgery Department

► Caregiver support group

► Geriatric Resource Nurse Council54

Staff Engagement

• Leadership Selection

► Emergency department/geriatric experience

• Staff selection (dedicated unit staff)

► Staff must want to be there; embrace geriatric care

► Geriatric-trained nurse practitioner and social worker

► Staff clinicians (All registered nurses must complete updated Geriatric Emergency Nursing Education program by Emergency Nurses Association)

► About 75 nurses within the organization have completed Nurses Improving Care to Health System Elders training to be a Geriatric Resource Nurse

55

Follow up

• All Seniors discharged from the Emergency Department receive a call back from social worker

► Facilitates follow up with primary care physician

► Offers further services (if required)

► Provides family support as needed (respite care)

• Polypharmacy review continues for all patients on 5 or more medications (approximately 80% of all patients)

56

Questions?

Click me to get Q&A box to appear

57

IPFCC Resources

58

http://www.ipfcc.org/index.html www.ipfcc.org/bettertogether/

Additional Resources

• Cacioppo, J. T., & Hawkley, L. C. (2003). Social isolation and health with an emphasis on underlying mechanisms. Perspectives in Biology and Medicine, 46(3), S39-S52.

• Clark P. A., Drain, M., & Malone, M. P. (2003). Addressing patients' emotional and spiritual needs. Joint Commission Journal on Quality and Safety, 29(12), 659-70.

• Ehlenbach, W. J., Hough, C. L., Crane, P. K., Haneuse, S. J., Carson, S. S., Curtis, J. R., & Larson, E. B. (2010). Association between acute care and critical illness hospitalization and cognitive function in older adults. JAMA, 303(8), 763-77.

59

Additional Resources

• Spencer, P. (2008). The security case for patient and family centered care. Journal of Healthcare Protection Management, 24(2), 1-5.

• Spencer, P. (2012). Security’s Role in PFCC. Journal of Healthcare Protection Management, 28(2), 30-34.

60

AHRQ Resources

•Guide to Patient and Family Engagement in Hospital Quality and Safety

•Patient Centered Medical Home (PCMH) Resource Center►Engaging Patients and Families in

the Medical Home

►Strategies to Put Patients at the Center of Primary Care

61

The Innovations Exchange

• Visit our Web site

► http://www.innovations.ahrq.gov/

► Frontline Innovators on Providing Patient- and Family-Centered Care Videos

• Follow us on Twitter:

#AHRQIX

• Send us email:

info@innovations.ahrq.gov

62